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Pel-Air and CASA damned by safety audit documents

The only tenable conclusion that can be made from the Pel-Air disclosures on 4 Corners last night is that the performances of CASA and the ATSB are so bad that they constitute a threat to public safety in Australia.

It is fortunate that those disclosures related to the ditching near Norfolk Island of an air ambulance flight in which all six people survived, and not the deaths of hundreds of people in the crash of an airliner operator by an Australian airline that neither organisation dares to touch.

Under background documents Pel-Air responds to the hitherto confidential audit of its operations as follows.

That response shows that Pel-Air is in total denial as to the substance of the audit’s findings, which are also posted in the same location.

Here are some additional extracts from an audit that CASA doesn’t want the public to be able to access when it exercises any choice in air services, or in this case, that responsible state authorities might exercise in the awarding of contracts for aerial ambulance work.

What is extraordinary about the above conclusion is the reference to ‘deficiencies … not identified or rectified, which is indicative of broader organisation failures.’

This was not the first Pel-Air audit conducted by CASA. Its previous audit is understood to have failed to identify these grievous issues, and CASA ought to be required to release that audit and explain whether Pel-Air fell into sudden and near disastrous decline in terms of standards in a short period of time, or was given a free pass for reasons that it ought to be compelled to disclose to an appropriate independent inquiry.

What on earth was going on in CASA, as the safety regulator and enforcer, to allow a situation more akin to a struggling and corrupt third world economy to prevail and permit such deficiencies to exist in an Australian operation?

Record keeping is a fundamental obligation on a properly licensed air operator. As a Level One nation in terms of its air safety performance, we are tolerating level two incompetency in a carrier.

At the very least, CASA ought to have used the same courage it displayed in grounding Tiger Airways as an imminent threat to safety, and served it with a show cause notice.

Pel-Air’s failings were many, and sudden, given the previous audit. Was that audit a rubber stamp exercise, or just the application of craven incompetency? Answers are needed, and ought to be demanded by the responsible minister, or a urgent and high powered and tightly focused parliamentary inquiry.

CASA, which had been trusted to make a comprehensive assessment of its application for an AOC, concedes in this late 2009 audit that Pel-Air didn’t even have a policy about obstacle avoidance, which is very relevant at some of the air strips likely to be used for medical flights, and always a critical factor in calculating operational performance in the event of an engine failure at a point where an aircraft can no longer stop before reaching the end of a runway.

The Pel-Air incident ought to be a lightning rod for immediate action by federal parliament, with some remedial action in terms of transparency as a legislative priority followed by an appropriate committee hearing and ministerial intervention at the top of CASA, the air safety regulator, and the ATSB, the air safety investigator.

CASA and the ATSB ought not be responding to this report, but to a parliament seized with the seriousness of these failings in the public administration of air safety.

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  • 1
    comet
    Posted September 4, 2012 at 10:50 am | Permalink

    The US State Department noted its grave fears about poor aviation safety in Australia, which were revealed in a Wikileaks document which surfaced in August 2011. The document revealed the US FAA discussed downgrading Australia to third-world Category 2 aviation status. Alarm bells should have been ringing then.

    There was real blood on the hands of those who survived the Pel-Air crash, and were forced to tread water in the black of night. There should be a Royal Commission, but despite almost five years in office Minister Albanese has done nothing but allowed safety standards to deteriorate. The minister will have blood on his hands after the inevitable disaster that his inaction will cause.

  • 2
    Stan Van de wiel
    Posted September 4, 2012 at 2:59 pm | Permalink

    Regular audits should be a welcome part of commercial aviation and these should contribute to both commercial requirements vs safety aspects. When such audits are carried out by the very few competent staff members of CASA who can only read and compare with their notes, it is an audit which does not contribute to anything apart from the CASA funds at $250 + per hour.
    In the first place when CASA check operations manuals for compliance they check for compliance with the regulations. Consider that some 50+% of the regulations are based on ( old) commercial rules there are few safety guards left. Secondly as CASA no longer sign off or “approve” an ops manual, there is no recourse, certainly no value for money. Non compliance in the Pelair case should have meant immediate loss of AOC.
    Political clout does have its value!
    When Albanese takes up the position of Chairman at Tiger, we will at least see a level playing field in the airline side of safety.

  • 3
    Stan Van de wiel
    Posted September 4, 2012 at 3:10 pm | Permalink

    If only John Quadrio had not avoided those birds he could have carried out a perfect ditching and probably never lost his license, income and nest egg? Career but then again he wasn’t repentant for something he didn’t do!

    The message to all Australian pilots is never avoid a natural calamity if you want to keep your license. Hull losses is what insurance is for and likely the insurance company will assist with your legals. With such backing CASA wouldn’t dare!
    Note if the “Hudson” river had been Botany Bay, Capt Scully would have been executed by CASA for failure to have a proper “bird” avoidance procedure in place.

    Empty Skies are Safe Skies.

  • 4
    SD
    Posted September 4, 2012 at 5:11 pm | Permalink

    I was surprised to see reference in 4 Corners to the role of John Sharp, former Minister of Transport on the Board of Rex, the parent company of Pel-air.

    I just hope that CASA officials were not looking after the interests of their former boss? Or am I too cynical?

  • 5
    Geoff
    Posted September 4, 2012 at 6:03 pm | Permalink

    Ben – What is your basis for this statement?
    “As a Level One nation in terms of its air safety performance…..”
    Your own disclosures indicate that we are not at level one.

  • 6
    The Insider
    Posted September 4, 2012 at 6:06 pm | Permalink

    The Chief Pilot of Pel Air at the time of this accident (John Wikham) is now working for CASA….seriously.

  • 7
    Ben Sandilands
    Posted September 4, 2012 at 6:54 pm | Permalink

    Geoff,

    But we are officially level one, and if I were to become cynical, I might suggest that we are level one only because of diplomatic pressure applied by a loyal ally who promised to do better. We are clearly not doing better, our regulatory regime is weak or compromised, and our level two antics may lead us to level two rating. Unless we crank up the pleadings and beggings. If being busted to level two can happen to Israel, it is not out of reach of CASA at all.

  • 8
    fractious
    Posted September 4, 2012 at 8:59 pm | Permalink

    @ The Insider @SD, it’s almost a join-the-dots exercise.

  • 9
    Scott
    Posted September 4, 2012 at 10:47 pm | Permalink

    I am watching the 4-Corners show now on the ABC web site and my mouth is hanging open. I have never done this on the internet before but I am going to describe John McCormick as snide, dissembling, and lacking the moral and professional courage, and intellectual independence of thought necessary to give any meaning to the title of “Director of Aviation Safety”.

    Of course the failures by the pilot are manifold, but for Mr McCormick to almost *snigger* as he suggests that pilots ought to be able to plan their flights long-hand is breathtaking.

    Which pilots, Mr McCormick, do you wish to refer to? And why, Mr McCormick, do you see fit to raise the comparison?

    I will not argue that pilots should not be able to plan a flight long-hand, but the fact is the software is sold for a purpose that Mr McCormick has chosen not to dispute. It would certainly be within his remit.

    What makes Mr McCormick’s insinuation breathtaking is the pretence that the flight plan as prepared is solely, directly and only proof of an incompetence at the point of the pilot. A pilot managed by a company and surrounded by other pilots where it is clear *no* other standard of flight planning is possible. If “inadequate” may be termed a standard.

    If I expected the pilot to be solely responsible for all the outcomes of a flight, I should logically resent the public funds spent on CASA and the ATSB. The fact that even Mr McCormick does not resent the public funding of CASA is an irony I choose not to characterise.

    I am sorry how angry this makes me. If Crikey needs to censor my comment, I will understand.

  • 10
    David Klein
    Posted September 6, 2012 at 10:24 am | Permalink

    Unfortunately when former CASA CEO Bruce Byron announced some years ago that the focus of the regulator would be on fare paying passenger operations with Aerial Work and Private operations almost left to their own devices with limited oversight, the Pel Air history of breaching the rules under Aerial Work was always going to continue.

  • 11
    Muppett monitor
    Posted September 6, 2012 at 2:30 pm | Permalink

    No surprises at all. I used to work for these guys and this is just the tip of the iceberg!

  • 12
    wildsky
    Posted September 10, 2012 at 1:33 am | Permalink

    Yes, the heads of CASA and the ATSB were made to look silly – but I would suggest that we only saw carefully selected and edited bits of much longer and probably much more considered interviews. Typically, 15 seconds of a total of 15 minutes of footage may make to air – it would be nice to see the whole interview to properly judge the players.

    Why didn’t the ABC explore the role of the company management in the conduct of these flights? Where was the oversight of the Chief Pilot? And, despite the easy journalistic suggestion that the pilot was made a scapegoat (although I think CASA got that bit right!), why didn’t they pursue the role of the assigned inspector and the clear lack of oversight revealed by their own post-event audit?

    This was one Four Corners investigation that I found quite disappointing for what it chose not to explore…

  • 13
    Ben Sandilands
    Posted September 10, 2012 at 5:43 am | Permalink

    Wilksky,

    As was patiently explained in the 4 Corners report, and here, and even hyperlinked in the reports published here, the complete 18minutes of the uncut interview with Dolan as well as with McCormick were posted, and my reports were written after doing what I think most interested and fair minded people would have done, which was to view them, several times, and take notes.

    As subsequently reported, the Chief Pilot subsequently left the employment of Pel-Air and took a position with CASA.

    My understanding is that the program is contemplating a second follow up report dealing with certain issues that couldn’t be fully explored or vetted legally within the length of the format nor the schedule for the program, which includes other issues in Australian public life which also come within its investigative scope.

    It has to make its choices according to different criteria to the choices we might make, but I’m very pleased that it did this report, and I’m also pleased that a number of those who were on board the flight did what I urged, and went to 4 Corners.

  • 14
    Posted September 13, 2012 at 3:27 pm | Permalink

    Good on ya Ben for sticking with this.
    As I write this, Thu 13th September afternoon, just heard that Senator Xenophon as successfully pushed for a Senate inquiry into all this. Lots more to come.

    Great investigative reporting will help change the industry and save lives!

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